Thursday, May 14, 2009

on complications

one of the most difficult parts of my job is figuring out when i did something wrong versus when i did everything i could and the inevitable just happened.

on sunday last week, i was presented with a dog that had a possible foreign body. her owner - we'll call her ms smith - was very good friends with a veterinarian (also a shareholder in our clinic). dr X saw the pet on saturday for lethargy, diarrhea, and anorexia of 2 days duration. no diagnostics were done, although the owner reported that "pup" had a bad habit of eating things he shouldn't. dr X prescribed an anti-emetic and sent the dog home. on sunday, she saw the dog again and noted cranial abdominal pain. the dog was sent to me.

xrays revealed at least 3 foreign bodies in the stomach and small intestines - hair elastics.

foreign bodies in dogs can run the gamut from bad to really, really bad. in this dog's case, we were dealing with a linear FB (the worst). your intestines are always gently (and sometimes not so gently) squeezing in a direction away from your stomach. this is called peristalsis and it moves in waves through the intestines. if a dog eats a string that gets partially hung in the stomach, but much of it passes through into the intestines, the intestines will continue to squeeze along. however, they won't be able to move that string, so they will bunch up on the string (just like the drawstring on your pants will do). eventually that string will saw right through the delicate gastrointestinal tissue, leading to spillage of feces into the abdomen. linear foreign bodies are BADNESS - especially when they've been present for THREE WHOLE DAYS.

i took the dog to surgery and removed 2 hair elastics from the stomach, as well as a mass of carpet like material. one of the hair elastics passed into the intestines, and due to the damage done, i had to cut out about 2 inches of small intestine.

24 hours post-operatively, the dog became horribly depressed and began vomiting. the owners refused to go back to surgery to let us find out what was going on. they elected to euthanize and take the body home.

i am left with the following options:

1) my surgical site failed and leaked into the abdomen2) contamination of the abdomen during surgery led to peritonitis3) the bowel that i thought appeared still viable was in fact too damaged to survive

the real kicker?

the vet that referred this dog is throwing a fit that i (yes, ME) did the surgery. supposedly i'm not supposed to do surgery - since i'm JUST an intern. no matter that i'm 1 month from the end of my internship, that i've done many of these surgeries (probably more than dr X has this year) - hell, i've done more than 50 surgeries this year, some much more complicated than that, that i've been hired as an ER doctor already to do just this kind of thing, and finally - the fact that this was a LINEAR FOREIGN BODY THAT HAD BEEN SITTING THERE FOR 3 DAYS! i'm being raked over the coals for a complication that has been reported to occur in up to 16% of these patients post-operatively.

in this situation, i'm left wondering: was it something i did wrong surgically? did i make a mistake and leave bowel that i should have taken out? did i ligate something that i shouldn't have? i'll never know for sure. i do know that every time i do surgery, i learn something new, i also look for my culpability, and i always take a failure (surgical or otherwise) to heart. it's hard enough to learn and forgive yourself without other vets ganging up on you!

5 comments:

Anonymous
said...

You caught the other doc's error and he's reacting to this, therefore, the best thing for him to do is make it your fault and throw a hissy.I'm not a vet but it sounds like you did all you could and the outcome was inevitable.

Not knowing is always crappy. My hospitalized patient died unexpectedly overnight. Did I miss something, was it sicker than I thought, or was it something we really couldn't have anything about. It's still tough but you just gotta trust yourself sometimes. You can only do what the owners will let you.

I think that you did everything that you could and things sometimes are meant to happen. I really like your web page and you are doing a wonderful job for the animals. I have always loved animals and I now have my own blog also. It is www.catsbestfriend.com

Yeh, with me, interns are not allowed to see any cases directly referred over from the regular vet. Because the reg vets think that someone who is almost done with an emergency internship has no idea how to correctly treat their patient who has an emergency. Crazy.

DISCLAIMER

Any similarity between my stories and any person or animal, living or dead, is strictly a coincidence. Names, breeds, sexes, and details of the stories have been changed to protect the guilty and innocent alike.

About Me

I am an emergency veterinarian in North Carolina. Despite the crazy people I deal with, the awful cases of injured and sick animals, and the overall stress of emergency work, I absolutely love what I do. Happily married since I was 20, I have a wonderful husband who has a PhD in Mathematics, and a daughter around whom our world currently revolves. We also have a zoo living in our house that can be alternately wonderful and maddening. There are cats, parrots, and a dog who is very low on the totem pole. Our days are never dull and we are learning to balance the demands of work and family.
If you'd like to contact me: homelessparrot@gmail.com

Human gross-ness

Followers

Medical terminology

Lactate - a salt/ester of lactic acid that is produced as energy for a cell when oxygen levels are low. In critically ill animals, elevated lactate can be an indicator of inadequate blood flow to organs (perfusion), decreased delivery of oxygen, and/or decreased oxygen uptake. Values > 6-7 are usually considered to be poor prognostic indicators for survival.

GI sloughing: when the cells lining the GI tract die (can be secondary to MANY things, including heatstroke) with resulting bloody diarrhea, bacterial translocation into the bloodstream and sepsis

TTJ: transfer to jesus: code for when an animal needs to be euthanized or die

DIC: disseminated intravascular coagulation: a very, very bad thing - when the hemostatic system gets out of whack, and clots start forming in the blood vessels until all clotting factors are wasted. once those are gone, internal hemorrhage ensues, followed by death, usually. also known as "death is coming"

Pleural effusion - fluid contained in the pleural space (chest) - this is not the same as fluid in the lungs (see pulm edema) - in cats can be caused by infection in the chest, heart failure, cancer, FIP, feline leukemia, FIV, and in some cases, the cause is never found (idiopathic)

Anisocoria - unequal pupil size (related to any number of causes including brain damage/head trauma)

Sepsis - refers to a bacterial infection in the bloodstream or body tissues. This is a very broad term covering the presence of many types of microscopic disease-causing organisms.

Nephrectomy - kidney removal

Splenectomy - removal of spleen

Pulmonary edema - condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately ( can be caused by heart failure, electrocution, drowning, too many IV fluids, to name a few)

Tick borne diseases - any of a myriad of diseases transmitted by ticks - including but not limited to Rocky Mtn Spotted fever, Lyme disease, Ehrlichia

Fine needle aspirate - A method of sampling in which a needle is used to suck in cells or tissue bits for diagnoses (good for diagnosing masses/lumps)

Blood glucose - The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence of insulin (normal range in a dog/cat is 75-100)

Diseases I see/treat frequently

Dystocia - difficulty birthing. May be responsive to oxytocin administration (Pitocin, as in people) but may require c-section.

DKA - diabetic ketoacidosis: the extreme end of the diabetic scale. A patient that is diabetic can develop DKA when other diseases make the blood glucose hard to regulate. Other diseases that are commonly associated include urinary tract infection, pancreatitis, pyometra, skin infection, and cancer. In DKA, the body starts metabolizing fat and producing acids that cause a drop in blood pH, nausea, weakness, severe dehydration, electrolyte derangments, and death.

DCM - dilated cardiomyopathy: an idiopathic (cause unknown) cardiac disease in which the heart chambers become very thin/dilated, and cardiac output drops radically. Causes arrhythmias, tachycardia, and sudden death. Seen in large breed dogs like Dobermans, Great Danes, etc.

Lymphoma - cancer of the white blood cells, the most common and treatable form of cancer in dogs

Blocked cat - slang term for a male cat with a plug of mucus and crystals obstructing the urethra (fairly common in male cats) definitely a life-threatening because urine can't get out of the body! If present long enough, causes shock, acute renal failure, hyperkalemia (elevated potassium), coma, and death. Symptoms include straining in the litterbox, yowling while trying to urinate, producing small, bloody drops of urine (also symptoms of feline cystitis, a non-lethal condition)

GDV - stands for gastric-dilatation and volvulus - a condition of large breed, deep-chested dogs (usually) in which the stomach rotates 180 degrees on its axis and thus - nothing can enter or leave, considered the "mother of all emergencies" - it warrants immediate surgery and carries a guarded prognosis

IMHA - immune-mediated hemolytic anemia. A disease in which the immune system attacks the red blood cells and destroys them. It causes profound anemia and is life-threatening. Causes are primary (no known cause) and secondary ( tick borne disease, cancer, and heavy metal intoxication). Treatment is immunosuppression with drugs primarily. Prognosis is guarded at best.